skip to main content

Adrenal crisis — DCH MCQ

Instant feedback + full explanation. One question, done properly.

HardPaediatric emergenciesAdrenal crisisDCH

A 5-year-old boy with congenital hypopituitarism takes regular hydrocortisone and levothyroxine. During 24 hours of vomiting, he has been unable to retain his hydrocortisone, including attempted sick-day doses. He is drowsy, with a heart rate of 142 beats/minute, capillary refill time of 4 seconds and blood pressure of 72/40 mmHg. His temperature is 37.3°C. Blood tests show glucose 2.6 mmol/L, sodium 128 mmol/L and potassium 4.2 mmol/L. He remains hypotensive after an initial 10 mL/kg bolus of 0.9% sodium chloride. What is the most likely diagnosis?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: B — Adrenal crisis

This is an adrenal crisis precipitated by vomiting and failure to absorb stress-dose hydrocortisone. The decisive features are established secondary adrenal insufficiency, hypoglycaemia, hyponatraemia, drowsiness and shock that persists after initial fluid resuscitation. A normal potassium does not exclude adrenal crisis in secondary adrenal insufficiency. Gastroenteritis may be the trigger, but uncomplicated hypovolaemia does not adequately explain this endocrine pattern. Septic shock remains an important concurrent differential but is less likely without a septic focus and with a clear interruption of glucocorticoid replacement. SIADH may cause hyponatraemia but not hypoglycaemic shock, while ketotic hypoglycaemia does not explain the hypotension and hyponatraemia. Emergency parenteral hydrocortisone and resuscitation must not be delayed for confirmatory cortisol testing.

Reference: National Institute for Health and Care Excellence. NG243: Adrenal insufficiency—identification and management, sections 1.6 and 1.7. 2024. https://www.nice.org.uk/guidance/NG243/chapter/recommendations